Rural Development and Malaria Control in Sub-Saharan Africa

The rapidly expanding population of Sub-Saharan Africa has led to an increased demand for land in which to live and grow food. The process of rural development continues to change the physical landscape, increasing mosquito breeding and biting rates of the chief vector of malaria in Africa, Anopheles gambiae, a mosquito exquisitely adapted for exploiting people. At the same time, development alters the social environment, affecting wealth, inequality, household entitlements, and male and female workloads, which lead to changes in coping and caring strategies. Despite the fact that malaria is sensitive to changes in the physical and social environment, most control tools use only chemicals (antimalarials and insecticides), not biophysical environmental modifications nor strengthening social systems. While antimalarials and insecticides are extremely effective weapons, they are probably not sustainable in the long term due to the emergence of resistant organisms. Here we suggest that environmental and social management should be considered as part of the suite of interventions against malaria, since these are likely to be effective in specific settings and represent a sustainable approach to malaria control in rural Africa.     

Neglected Fungal Diseases in Sub-Saharan Africa: A Call to Action

Despite the considerable morbidity and mortality associated with fungal diseases in sub-Saharan Africa, it is notable that these diseases have been omitted from an expanded list of neglected tropical diseases. Inextricably tied together with HIV/AIDS and tuberculosis in sub-Saharan Africa, important fungal diseases such as cryptococcal meningitis and Pneumocystis jirovecii pneumonia (PCP) manifest as relatively common and deadly AIDS-defining opportunistic infections, often masked by and comorbid with tuberculosis. Others, such as mycetoma, which manifest as a debilitating and deforming illness primarily affecting rural adults, directly affect the socioeconomic productivity of rural communities. Lack of adequate diagnostic tests makes identifying the true disease burden due to fungal diseases difficult. To highlight the devastating impact of fungal diseases on the health and socioeconomic circumstances of sub-Saharan Africa’s poorest people and to increase the profile of efforts to control and prevent these diseases, we propose that the following fungal diseases be added to the list of neglected tropical diseases: cryptococcal meningitis, PCP, mycetoma, histoplasmosis, sporotrichosis, and blastomycosis. By outlining the prevalence, distribution, and disease burden of these fungal diseases in sub-Saharan Africa in this review, we hope to provide information to prioritize strategies for detection, control, and prevention of the neglected fungal diseases.     

Assessing and Responding to Palliative Care Needs in Rural Sub-Saharan Africa: Results from a Model Intervention and Situation Analysis in Malawi

Introduction

Palliative care is rarely accessible in rural sub-Saharan Africa. Partners In Health and the Malawi government established the Neno Palliative Care Program (NPCP) to provide palliative care in rural Neno district. We conducted a situation analysis to evaluate early NPCP outcomes and better understand palliative care needs, knowledge, and preferences.

Methods

Employing rapid evaluation methodology, we collected data from 3 sources: 1) chart review of all adult patients from the NPCP’s first 9 months; 2) structured interviews with patients and caregivers; 3) semi-structured interviews with key stakeholders.

Results

The NPCP enrolled 63 patients in its first 9 months. Frequent diagnoses were cancer (n = 50, 79%) and HIV/AIDS (n = 37 of 61, 61%). Nearly all (n = 31, 84%) patients with HIV/AIDS were on antiretroviral therapy. Providers registered 112 patient encounters, including 22 (20%) home visits. Most (n = 43, 68%) patients had documented pain at baseline, of whom 23 (53%) were treated with morphine. A majority (n = 35, 56%) had ≥1 follow-up encounter. Mean African Palliative Outcome Scale pain score decreased non-significantly between baseline and follow-up (3.0 vs. 2.7, p = 0.5) for patients with baseline pain and complete pain assessment documentation. Providers referred 48 (76%) patients for psychosocial services, including community health worker support, socioeconomic assistance, or both. We interviewed 36 patients referred to the NPCP after the chart review period. Most had cancer (n = 19, 53%) or HIV/AIDS (n = 10, 28%). Patients frequently reported needing income (n = 24, 67%) or food (n = 22, 61%). Stakeholders cited a need to make integrated palliative care widely available.

Conclusions

We identified a high prevalence of pain and psychosocial needs among patients with serious chronic illnesses in rural Malawi. Early NPCP results suggest that comprehensive palliative care can be provided in rural Africa by integrating disease-modifying treatment and palliative care, linking hospital, clinic, and home-based services, and providing psychosocial support that includes socioeconomic assistance.     

Leveraging Rapid Community-Based HIV Testing Campaigns for Non-Communicable Diseases in Rural Uganda

BACKGROUND: The high burden of undiagnosed HIV in sub-Saharan Africa limits treatment and prevention efforts. Community-based HIV testing campaigns can address this challenge and provide an untapped opportunity to identify non-communicable diseases (NCDs). We tested the feasibility and diagnostic yield of integrating NCD and communicable diseases into a rapid HIV testing and referral campaign for all residents of a rural Ugandan parish. METHODS: A five-day, multi-disease campaign, offering diagnostic, preventive, treatment and referral services, was performed in May 2011. Services included point-of-care screening for HIV, malaria, TB, hypertension and diabetes. Finger-prick diagnostics eliminated the need for phlebotomy. HIV-infected adults met clinic staff and peer counselors on-site; those with CD4≤100/μL underwent intensive counseling and rapid referral for antiretroviral therapy (ART). Community participation, case-finding yield, and linkage to care three months post-campaign were analyzed. RESULTS: Of 6,300 residents, 2,323/3,150 (74%) adults and 2,020/3,150 (69%) children participated. An estimated 95% and 52% of adult female and male residents participated respectively. Adult HIV prevalence was 7.8%, with 46% of HIV-infected adults newly diagnosed. Thirty-nine percent of new HIV diagnoses linked to care. In a pilot subgroup with CD4≤100, 83% linked and started ART within 10 days. Malaria was identified in 10% of children, and hypertension and diabetes in 28% and 3.5% of adults screened, respectively. Sixty-five percent of hypertensives and 23% of diabetics were new diagnoses, of which 43% and 61% linked to care, respectively. Screening identified suspected TB in 87% of HIV-infected and 19% of HIV-uninfected adults; 52% percent of HIV-uninfected TB suspects linked to care. CONCLUSIONS: In an integrated campaign engaging 74% of adult residents, we identified a high burden of undiagnosed HIV, hypertension and diabetes. Improving male attendance and optimizing linkage to care require new approaches. The campaign demonstrates the feasibility of integrating hypertension, diabetes and communicable diseases into HIV initiatives.     

Medical Expenditure for Chronic Diseases in Mexico: The Case of Selected Diagnoses Treated by the Largest Care Providers

Background

Chronic diseases (CD) are a public health emergency in Mexico. Despite concern regarding the financial burden of CDs in the country, economic studies have focused only on diabetes, hypertension, and cancer. Furthermore, these estimated financial burdens were based on hypothetical epidemiology models or ideal healthcare scenarios. The present study estimates the annual expenditure per patient and the financial burden for the nine most prevalent CDs, excluding cancer, for each of the two largest public health providers in the country: the Ministry of Health (MoH) and the Mexican Institute of Social Security (IMSS).

Methods

Using the Mexican National Health and Nutrition Survey 2012 (ENSANUT) as the main source of data, health services consumption related to CDs was obtained from patient reports. Unit costs for each provided health service (e.g. consultation, drugs, hospitalization) were obtained from official reports. Prevalence data was obtained from the published literature. Annual expenditure due to health services consumption was calculated by multiplying the quantity of services consumed by the unit cost of each health service.

Results

The most expensive CD in both health institutions was chronic kidney disease (CKD), with an annual unit cost for MoH per patient of US$ 8,966 while for IMSS the expenditure was US$ 9,091. Four CDs (CKD, arterial hypertension, type 2 diabetes, and chronic ischemic heart disease) accounted for 88% of the total CDs financial burden (US$ 1.42 billion) in MoH and 85% (US$ 3.96 billion) in IMSS. The financial burden of the nine CDs analyzed represents 8% and 25% of the total annual MoH and IMSS health expenditure, respectively.

Conclusions/Significance

The financial burden from the nine most prevalent CDs, excluding cancer, is already high in Mexico. This finding by itself argues for the need to improve health promotion and disease detection, diagnosis, and treatment to ensure CD primary and secondary prevention. If the status quo remains, the financial burden could be higher.     

The Harbin Cohort Study on Diet,Nutrition and Chronic Non-Communicable Diseases: Study Design and Baseline Characteristics

Diet and nutrition have been reported to be associated with many common chronic diseases and blood-based assessment would be vital to investigate the association and mechanism, however, blood-based prospective studies are limited. The Harbin Cohort Study on Diet, Nutrition and Chronic Non-communicable Diseases was set up in 2010. From 2010 to 2012, 9,734 participants completed the baseline survey, including demographic characteristics, dietary intake, lifestyles and physical condition, and anthropometrics. A re-survey on 490 randomly selected participants was done by using the same methods which were employed in the baseline survey. For all participants, the mean age was 50 years and 36% of them were men. Approximately 99.4 % of cohort members donated blood samples. The mean total energy intake was 2671.7 kcal/day in men and 2245.9 kcal/day in women, the mean body mass index was 25.7 kg/m² in men and 24.6 kg/m² in women, with 18.4% being obese (≥28 kg/m²), 12.7% being diabetic, and 29.5% being hypertensive. A good agreement was obtained for the physical measurements between the baseline survey and re-survey. The resources from the cohort and its fasting and postprandial blood samples collected both at baseline and in each follow-up will be valuable and powerful in investigating relationship between diet, nutrition and chronic diseases and discovering novel blood biomarkers and the metabolism of these biomarkers related to chronic diseases.     

The Challenge of AIDS-Related Malignancies in Sub-Saharan Africa

Background

With the lengthening of life expectancy among HIV-positive subjects related to the use of highly active antiretroviral treatments, an increased risk of cancer has been described in industrialized countries. The question is to determine what occurs now and will happen in the future in the low income countries and particularly in sub-Saharan Africa where more than two-thirds of all HIV-positive people live in the world. The objective of our paper is to review the link between HIV and cancer in sub-Saharan Africa, putting it in perspective with what is already known in Western countries.

Methods and Findings

Studies for this review were identified from several bibliographical databases including Pubmed, Scopus, Cochrane, Pascal, Web of Science and using keywords “HIV, neoplasia, epidemiology and Africa” and related MesH terms. A clear association was found between HIV infection and AIDS-classifying cancers. In case-referent studies, odds ratios (OR) were ranging from 21.9 (95% Confidence Interval (CI) 12.5–38.6) to 47.1 (31.9–69.8) for Kaposi sarcoma and from 5.0 (2.7–9.5) to 12.6 (2.2–54.4) for non Hodgkin lymphoma. The association was less strong for invasive cervical cancer with ORs ranging from 1.1 (0.7–1.2) to 1.6 (1.1–2.3), whereas ORs for squamous intraepithelial lesions were higher, from 4.4 (2.3–8.4) to 17.0 (2.2–134.1). For non AIDS-classifying cancers, squamous cell conjunctival carcinoma of the eye was associated with HIV in many case-referent studies with ORs from 2.6 (1.4–4.9) to 13.0 (4.5–39.4). A record-linkage study conducted in Uganda showed an association between Hodgkin lymphoma and HIV infection with a standardized incidence ratio of 5.7 (1.2–17) although OR in case-referent studies ranged from 1.4 (0.7–2.8) to 1.6 (1.0–2.7). Other cancer sites found positively associated with HIV include lung, liver, anus, penis, vulva, kidney, thyroid and uterus and a decreased risk of female breast cancer. These results so far based on a relatively small number of studies warrant further epidemiological investigations, taking into account other known risk factors for these tumors.

Conclusion

Studies conducted in sub-Saharan Africa show that HIV infection is not only strongly associated with AIDS-classifying cancers but also provided some evidence of association for other neoplasia. African countries need now to implement well designed population-based studies in order to better describe the spectrum of AIDS-associated malignancies and the most effective strategies for their prevention, screening and treatment.     

The Influence of Dams on Malaria Transmission in Sub-Saharan Africa

EcoHealth - The construction of dams in sub-Saharan Africa is pivotal for food security and alleviating poverty in the region. However, the unintended adverse public health implications of...     

High Mortality amongst Adolescents and Adults with Bacterial Meningitis in Sub-Saharan Africa: An Analysis of 715 Cases from Malawi

Mortality from bacterial meningitis in African adults is significantly higher than those in better resourced settings and adjunctive therapeutic interventions such as dexamethasone and glycerol have been shown to be ineffective. We conducted a study analysing data from clinical trials of bacterial meningitis in Blantyre, Malawi to investigate the clinical parameters associated with this high mortality.

Methods

We searched for all clinical trials undertaken in Blantyre investigating bacterial meningitis from 1990 to the current time and combined the data from all included trial datasets into one database. We used logistic regression to relate individual clinical parameters to mortality. Adults with community acquired bacterial meningitis were included if the CSF culture isolate was consistent with meningitis or if the CSF white cell count was >100 cells/mm³ (>50% neutrophils) in HIV negative participants and >5 cells/mm³ in HIV positive participants. Outcome was measured by mortality at discharge from hospital (after 10 days of antibiotic therapy) and community follow up (day 40).

Results

Seven hundred and fifteen episodes of bacterial meningitis were evaluated. The mortality rate was 45% at day 10 and 54% at day 40. The most common pathogens were S.pneumoniae (84% of positive CSF isolates) and N.meningitidis (4%). 607/694 (87%) participants tested were HIV antibody positive. Treatment delays within the hospital system were marked. The median presenting GCS was 12/15, 17% had GCS<8 and 44.9% had a seizure during the illness. Coma, seizures, tachycardia and anaemia were all significantly associated with mortality on multivariate analysis. HIV status and pneumococcal culture positivity in the CSF were not associated with mortality. Adults with community acquired bacterial meningitis in Malawi present with a severe clinical phenotype. Predictors of high mortality are different to those seen in Western settings. Optimising in-hospital care and minimising treatment delays presents an opportunity to improve outcomes considerably.     

Chronic Non-Communicable Disease and Healthcare Access in Middle-Aged and Older Women Living in Soweto,South Africa

The aim of the current study was to describe the healthcare access, beliefs, and practices of middle-aged and older women residing in Soweto. This is a cross-sectional study of the primary (female) caregivers of the Birth to Twenty Cohort, based in Soweto, South Africa. The study instrument was administered to 1 102 caregivers as part of routine annual data collection. Over half the respondents (50.7%) reported having at least one chronic non-communicable disease (CND), only a small portion (33.3%) of whom reported accessing a healthcare service in the last 6 months. Reported availability of private medical practice and government clinics was high (75.1% and 61.5% respectively). The low utilisation of healthcare services by women with CND is a concern in terms of healthcare management. There is a need to further investigate how healthcare beliefs are formed, as well as the feasibility of programmes to support the ongoing management of CND in Soweto.     

Neglected Tropical Diseases in Sub-Saharan Africa: Review of Their Prevalence,Distribution, and Disease Burden

The neglected tropical diseases (NTDs) are the most common conditions affecting the poorest 500 million people living in sub-Saharan Africa (SSA), and together produce a burden of disease that may be equivalent to up to one-half of SSA''s malaria disease burden and more than double that caused by tuberculosis. Approximately 85% of the NTD disease burden results from helminth infections. Hookworm infection occurs in almost half of SSA''s poorest people, including 40–50 million school-aged children and 7 million pregnant women in whom it is a leading cause of anemia. Schistosomiasis is the second most prevalent NTD after hookworm (192 million cases), accounting for 93% of the world''s number of cases and possibly associated with increased horizontal transmission of HIV/AIDS. Lymphatic filariasis (46–51 million cases) and onchocerciasis (37 million cases) are also widespread in SSA, each disease representing a significant cause of disability and reduction in the region''s agricultural productivity. There is a dearth of information on Africa''s non-helminth NTDs. The protozoan infections, human African trypanosomiasis and visceral leishmaniasis, affect almost 100,000 people, primarily in areas of conflict in SSA where they cause high mortality, and where trachoma is the most prevalent bacterial NTD (30 million cases). However, there are little or no data on some very important protozoan infections, e.g., amebiasis and toxoplasmosis; bacterial infections, e.g., typhoid fever and non-typhoidal salmonellosis, the tick-borne bacterial zoonoses, and non-tuberculosis mycobaterial infections; and arboviral infections. Thus, the overall burden of Africa''s NTDs may be severely underestimated. A full assessment is an important step for disease control priorities, particularly in Nigeria and the Democratic Republic of Congo, where the greatest number of NTDs may occur.     

Acute Myocardial Infarction in Sub-Saharan Africa: The Need for Data

Background

Trends in the prevalence of acute myocardial infarction in sub-Saharan Africa have not been well described, despite growing recognition of the increasing burden of cardiovascular disease in low- and middle-income countries. The aim of this systematic review was to describe the prevalence of acute myocardial infarction in sub-Saharan Africa.

Methods

We searched PubMed, EMBASE, Global Health Archive, CINAHL, and Web of Science, and conducted reference and citation analyses. Inclusion criteria were: observational studies, studies that reported incidence or prevalence of acute myocardial infarction, studies conducted in sub-Saharan Africa, and studies that defined acute myocardial infarction by EKG changes or elevation of cardiac biomarkers. Studies conducted prior to 1992 were excluded. Two independent reviewers analyzed titles and abstracts, full-texts, and references and citations. These reviewers also performed quality assessment and data extraction. Quality assessment was conducted with a validated scale for observational studies.

Findings

Of 2292 records retrieved, seven studies met all inclusion criteria. These studies included a total of 92,378 participants from highly heterogeneous study populations in five different countries. Methodological quality assessment demonstrated scores ranging from 3 to 7 points (on an 8-point scale). Prevalence of acute myocardial infarction ranged from 0.1 to 10.4% among the included studies.

Interpretation

There is insufficient population-based data describing the prevalence of acute myocardial infarction in sub-Saharan Africa. Well-designed registries and surveillance studies that capture the broad and diverse population with acute myocardial infarction in sub-Saharan Africa using common diagnostic criteria are critical in order to guide prevention and treatment strategies.

Registration

Registered in International Prospective Register of Systematic Reviews (PROSPERO) Database #CRD42012003161.     

The Epidemiology of Hypertension in Uganda: Findings from the National Non-Communicable Diseases Risk Factor Survey

Background

Hypertension is an important contributor to global burden of disease and mortality, and is a growing public health problem in sub-Saharan Africa. However, most sub-Saharan African countries lack detailed countrywide data on hypertension and other non-communicable diseases (NCD) risk factors that would provide benchmark information for design of appropriate interventions. We analyzed blood pressure data from Uganda’s nationwide NCD risk factor survey conducted in 2014, to describe the prevalence and distribution of hypertension in the Ugandan population, and to identify the associated factors.

Methods

The NCD risk factor survey drew a countrywide sample stratified by the four regions of the country, and with separate estimates for rural and urban areas. The World Health Organization’s STEPs tool was used to collect data on demographic and behavioral characteristics, and physical and biochemical measurements. Prevalence rate ratios (PRR) using modified Poison regression modelling was used to identify factors associated with hypertension.

Results

Of the 3906 participants, 1033 were classified as hypertensive, giving an overall prevalence of 26.4%. Prevalence was highest in the central region at 28.5%, followed by the eastern region at 26.4%, western region at 26.3%, and northern region at 23.3%. Prevalence in urban areas was 28.9%, and 25.8% in rural areas. The differences between regions, and between rural-urban areas were not statistically significant. Only 7.7% of participants with hypertension were aware of their high blood pressure. The prevalence of pre-hypertension was also high at 36.9%. The only modifiable factor found to be associated with hypertension was higher body mass index (BMI). Compared to participants with BMI less than 25 kg/m², prevalence was significantly higher among participants with BMI between 25 to 29.9 kg/m² with an adjusted PRR = 1.46 [95% CI = 1.25–1.71], and even higher among obese participants (BMI ≥ 30 kg/m²) with an adjusted PRR = 1.60 [95% CI = 1.29–1.99]. The un-modifiable factor found to be associated with hypertension was older age with an adjusted PRR of 1.02 [95% CI = 1.02–1.03] per yearly increase in age.

Conclusions

The prevalence of hypertension in Uganda is high, with no significant differences in distribution by geographical location. Only 7.7% of persons with hypertension were aware of their hypertension, indicating a high burden of undiagnosed and un-controlled high blood pressure. Thus a big percentage of persons with hypertension are at high risk of hypertension-related cardiovascular NCDs.